Forms

Request for Temporary Total Compensation (C-84)
Injured workers must use this form to initiate or extend payment of temporary total disability benefits. The injured worker provides information about employment and benefits received during the time of disability. The physician provides additional information on the Physician's Report of Work Ability (MEDCO-14).

Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability (C-92)
Injured workers should use this form to request an award for permanent impairment, either physical or psychological, resulting from an allowed workers' compensation claim. If an injured worker has a permanent impairment, he or she may be eligible for a monetary award based upon the severity of the impairment. The injured worker may be eligible for this award even if he or she did not lose time from work due to the injury.
If an injured worker has previously been granted a Percentage of Permanent Partial award, he or she can also use this form to request an increase to that award. Increases may be due to the impairment becoming more severe over time or because a new medical condition has been added to the claim.

Completing the Injured Worker Statement for Reimbursement of Travel Expense (C-60)
Injured workers use this form to request reimbursement for travel expenses incurred relative to a medical exam or treatment for a work-related injury or disease. Injured workers should send the completed form to BWC or their self-insuring employer.

A.C.T. Enrollment and Direct Deposit Authorization (A-12)
Injured workers should use this form to apply for direct deposit of their workers' compensation payments. Automatic Comp Transfer (ACT) deposits injured worker compensation payments into a checking or savings account of their choice on the day payment is due. Injured workers must send the form along with a voided check or personal deposit slip containing the banking information and account number to BWC ACT, P.O. Box 15429, Columbus, OH 43215-0429.